feature: Our highly sophisticated social networks make us more vulnerable to attack by disease.Can telemedicine offer us any protection, asks Peter Kruger

Published: 21/03/2002, Volume II2, No. 5797 Page 2 3

Aready meal, an airline terminal and a GP's personal computer all have one thing in common - they are components in networks.

In his book, Metaman, Gregory Stock describes such networks as society's equivalent of limbs and biological functions. Britain's food and water supply are part of a vast digestive system, while rail and airline networks are Metaman's arms and legs.

The GP's computer, meanwhile, is just a small part of Metaman's vital immune system, which has to be ready to spring into action if disease attacks a particular organ or limb.

Since the major epidemics of the Victorian era, the sophistication of public health systems has, by and large, kept pace with the sophistication of the networks diseases exploit. But some public health experts have recently concluded that Metaman may be losing this race. In his report Getting Ahead of the Curve, England's chief medical officer, Professor Liam Donaldson, points out that modern life is making us more vulnerable to attack.

The report cites global travel and the highly developed networks that deliver cheap food to consumers throughout the industrialised world as potential sources of disease. Airlines have compatible IT systems for reservations, engineering and support services - for passengers, air travel is normally a journey through one seamless network.

Similarly, food producers, processors, distributors and retailers have integrated IT systems to increase throughput and cut costs.

Much less well developed, where it exists at all, is the technology to alert those concerned with disease control to the presence of an airline passenger with a life-threatening disease or to quickly pinpoint a toxic element within the food chain.

As Professor Donaldson's report puts it: 'There is no integrated approach to encompass all aspects of health protection... from national, to regional, to local level.' The report proposes building a 'modern system' of agencies to prevent, investigate and control infectious diseases, working with 'modern methods of data capture' (see box 1).

In an effort to improve Europe's ability to monitor the spread of disease, meanwhile, the International Telecommunications Union and the EU are about to embark on a joint telemedicine programme.

'Until now, we have been trying to convince authorities in developing countries to use the internet for telemedicine applications, ' says Petko Kantchev, co-ordinator of the ITU technology and applications group.'We now have to move more towards monitoring and early warning of disease.'

This approach could be described as 'closing the drawbridge'. It tackles a problem at the boundaries of the developed world, instead of at its origins.

The ITU recently installed a broadband link between two hospitals in Uganda that allows them to share resources. This is important in a country where annual healthcare expenditure is just $4 per head per year.However, the project was relatively simple to set up. Projects to link villages and hospitals are much tougher. And even less 'sexy' projects to get good health information to individuals have been fraught with problems.

Before the internet enabled organisations like Africa Online to deliver web-based medical information, most telemedicine projects collapsed as soon as the funding ended.

This is not an issue confined to the undeveloped world. Spectacular diseases such as ebola and vCJD grab headlines, but in recent years, an ageing population and dull old influenza have come close to bringing the NHS to its knees.

Telemedicine also has a role in health promotion here: but PC ownership is heavily skewed towards the upper occupational groups, which traditionally have the best health.

Existing websites are also passive. In the US and Europe, companies have begun to use telemedicine for care applications (see box 2). But still missing is the 'middleware' to glue the low-level, mainly webbased, telemedicine to the core network where disease and health trends are monitored.

The modern supermarket, the user interface for our integrated food supply network, provides an illustration of the level of monitoring possible if the right middleware is in place.

Tesco's loyalty card system allows it to build a profile of each customer using 'customer relationship management' software. It can monitor a customer's behaviour in real time and make on-the-spot offers and purchasing suggestions.

Britain's nurse-led telephone helpline, NHS Direct, has some of the analytical tools present in early generations of CRM software.

'NHS Direct is a move towards 24/7 availability, ' says Helen Omwando, an analyst with Forrester Research. 'It is a step forward - but not a leap forward.'

NHS Direct is also playing a part in spotting disease. Algorithms have been designed, for example, to provide early indications of an impending flu epidemic.

But this still lacks the granularity of Tesco's CRM software. If Tesco fed data from its in-house pharmacies into the system, it would be able to monitor the health of individual shoppers - and much of the local population. But the collapse of the dot. com boom effectively stopped the spread of CRM in its tracks.

Another big issue is privacy. Tesco's systems are intrusive - but they offer sweeteners like vouchers and offers in return.Also, it may not matter much - nobody is refused a job or insurance for having a Pot Noodle addiction.Who collects and sees sensitive health information is a much more serious issue.

'Telemedicine is being used as an excuse to centralise data, ' says Ross Anderson of Cambridge University computer laboratory.He is worried about the spread of .Net - a development technology from Microsoft. This provides a 'platform' on which a diverse range of applications can run and, more importantly, exchange data.

This may be just the sort of thing the NHS, with its legacy of old, incompatible and underfunded systems, needs. But Mr Anderson warns it could also 'centralise all medical records in the UK.'

.NET also has an 'electronic passport'utility that enables Microsoft to maintain a degree of control over users, data and applications on any network developed using it.

But Mr Kantchev believes there must be limits to the privacy we can expect in the future.

'We are travelling more, diseases are spreading more rapidly. By accepting the principle of privacy, we are agreeing to return to the stone age, ' he says.

On the most pessimistic scenario, the issue of privacy is irrelevant.This scenario says Stock's Metaman is entering old age.As the population ages, health services collapse under the weight of a (globalised and ageing) population.Telemedicine, or automation of any other kind, will do little more to provide a degree of comfort in his twilight years.

Box 1: Getting ahead of the curve Professor Liam Donaldson argues that infectious diseases are 'a major global threat' to health, prosperity, social stability and even security.'A number of major national crises over the last few years have been a direct consequence of infectious diseases (eg BSE and vCJD, foot and mouth disease and NHS winter pressures).Potential threats are as diverse as poor hygiene and terrorist attack; and despite Britain's history of public health, 'the system falls short of what is necessary to fully protect the public'.

The report calls for a new infection control and health-protection agency, a local health-protection service and better monitoring systems.

Getting ahead of the curve: a strategy for infectious diseases www. doh. gov. uk/cmo/publications. htm

Box 2: never missing a beat

A British Medical Journal report says Californian managed-care organisation Kaiser Permanente achieves better performance at roughly the same cost as the NHS - through better integration throughout the system, more efficient use of hospital and better use of IT.But services that keep people out of hospital, such as distance nursing, are not cheap. If that cost is included, the comparison between the US and UK experience is not so favourable to Kaiser.

And developments are not limited to the US.Last July, prime minister Tony Blair launched a community telemedicine service developed through a partnership between Sedgefield borough council and British company Tunstall.Simple monitors allow patients to measure their blood pressure, heart and breathing rates, oxygen levels and temperature, and transmit the information to a central monitoring centre by telephone.Similar projects operate elsewhere.

Telemedicine is also used to link hospitals - BT Health has examples such as a project to link nine minor injuries units in Cornwall with major hospitals. It is becoming more common in pathology, x-ray and other support services.Agfa is installing a system allowing radiologists at South Tyneside District Hospital to view x-ray images from Palmer Community Hospital in Jarrow.Motion Media videophones are used to link St Andrew's Hospice in Grimsby with patients'homes.